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Hard, Tender Mass at the Submandibular Region and Trunk
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MODEL
Journal of Medical Ultrasound (2014) xx, 1e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jmu-online.com
IMAGING FOR RESIDENTS
Hard, Tender Mass at the Submandibular Region and Trunk Chee-Wai Mak 1,2*, Wen-Sheng Tzeng 1, Yu-Ting Kuo 1, I-Ha Lao 1 1
Department of Medical Imaging, Chi-Mei Medical Center, Yong Kang District, Tainan City, and Department of Medical Technology, Chung Hwa University of Medical Technology, Tainan, Taiwan, ROC
2
Case A 15-year-old female patient complained of having a hard lump over the left submandibular region for 3 months, and
Fig. 2 A calcified mass with acoustic shadow is seen in the subcutaneous layer of the right upper neck.
Fig. 1 A well defined oval heterogeneous masse with internal echogenic foci and peripheral hypoechoic rim is seen at subcutaneous layer of the left submandubular region.
the results of ultrasound examination are shown in Fig. 1. Surgical excision of the lesion was performed. However, 3 months later, another hard mass developed in the right upper neck and the sonographic feature of this lesion are shown in Fig. 2. What is your diagnosis? Are these two lesions related to each other?
Interpretation Conflicts of interest: All authors declare no conflicts of interest. * Correspondence to: Dr Chee-Wai Mak, Department of Medical Imaging, Chi-Mei Medical Center, Yong Kang District, Tainan City, Taiwan, ROC. E-mail address: [email protected] (C.-W. Mak).
Fig. 1 shows a well-defined 1.4 cm 1 cm oval heterogeneous mass with internal echogenic foci and a peripheral hypoechoic rim located in the subcutaneous layer of the left submandibular region. Surgical excision showed that
http://dx.doi.org/10.1016/j.jmu.2014.03.002 0929-6441
Please cite this article in press as: Mak C-W, et al., Hard, Tender Mass at the Submandibular Region and Trunk, Journal of Medical Ultrasound (2014), http://dx.doi.org/10.1016/j.jmu.2014.03.002
+
MODEL
2 this was a pilomatricoma. Fig. 2 shows a 1.1-cm calcified mass with an acoustic shadow in the subcutaneous layer of the right upper neck, which was also shown to be due to pilomatricoma, after surgical excision. Pilomatricoma also known as trichomatricoma, pilomatrixoma or calcifying epithelioma of Malherbe is an uncommon benign superficial tumor arising from the hair follicle. Pilomatricomas occur more often in children younger than 20 years old, with a slight female predominance. Frequently affected sites include the neck, head, and face, followed by the upper extremity. Patients affected usually present with an asymptomatic palpable mass with a rock-hard consistency and an irregular surface, which causes skin stretching over the mass. Most pilomatricomas have an excellent prognosis after complete surgical excision. Pilomatricomas are superficially located, small and movable masses, therefore, patients are usually treated without imaging studies. The sonographic features of pilomatricoma include: (1) a subcutaneous mass containing internal calcifications, internal echogenic foci, and a hypoechoic rim [1,2]; (2) an irregular, homogeneously hyperechoic mass with strong posterior acoustic shadowing [2]; and (3) a complex, pseudocystic lesion [3]. Furthermore, this tumor has been reported to be hypervascular [1,2,4], with 70% having peripheral color Doppler flow and 10% presenting with both central and peripheral color Doppler flow patterns [2]. The differential diagnosis includes epidermoid or dermoid cyst, salivary gland tumors, calcified lymph nodes, and hemangioma. Pilomatricoma can be distinguished from epidermoid and dermoid cysts by the presence of
C.-W. Mak et al. calcification and peripheral vascular flow. Epidermoid cysts appear as hypovascular masses with inner anechoic foci rather than echogenic foci and do not show vascular flow. Salivary gland tumors are deeply seated beneath the superficial fascia, whereas pilomatricomas are located within the subcutaneous layer. Hemangiomas are usually soft, their associated calcifications are round, and low frequency Doppler glows are evident within anechoic vascular channels. Most lymph nodes have central Doppler flow at their fatty hilum, whereas pilomatricomas tend to have peripheral Doppler flow. In conclusion, diagnosis of pilomatricoma should be considered when a well-defined mass with inner echogenic foci and a peripheral hypoechoic rim, or a completely echogenic mass with strong posterior acoustic shadowing in the subcutaneous layer of the head, neck, and extremity is found on ultrasonography.
References [1] Jin W, Kim GY, Park SY, et al. The spectrum of vascularized superficial soft-tissue tumors on sonography with a histopathologic correlation: part 1, benign tumors. AJR 2010;195: 439e45. [2] Hwang JY, Lee SW, Lee SM. The common ultrasonographic features of pilomatricoma. J Ultrasound Med 2005;24: 1397e402. [3] Solivetti FM, Elia F, Drusco A, et al. Epithelioma of Malherbe: new ultrasound patterns. J Exp Clin Cancer Res 2010;29:42. [4] Ichikawa T, Nakajima Y, Fujimoto H, et al. Giant calcifying epithelioma of Malherbe (pilomatricoma): imaging features. Skeletal Radiol 1997;26:602e5.
Please cite this article in press as: Mak C-W, et al., Hard, Tender Mass at the Submandibular Region and Trunk, Journal of Medical Ultrasound (2014), http://dx.doi.org/10.1016/j.jmu.2014.03.002
MODEL
Journal of Medical Ultrasound (2014) xx, 1e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jmu-online.com
IMAGING FOR RESIDENTS
Hard, Tender Mass at the Submandibular Region and Trunk Chee-Wai Mak 1,2*, Wen-Sheng Tzeng 1, Yu-Ting Kuo 1, I-Ha Lao 1 1
Department of Medical Imaging, Chi-Mei Medical Center, Yong Kang District, Tainan City, and Department of Medical Technology, Chung Hwa University of Medical Technology, Tainan, Taiwan, ROC
2
Case A 15-year-old female patient complained of having a hard lump over the left submandibular region for 3 months, and
Fig. 2 A calcified mass with acoustic shadow is seen in the subcutaneous layer of the right upper neck.
Fig. 1 A well defined oval heterogeneous masse with internal echogenic foci and peripheral hypoechoic rim is seen at subcutaneous layer of the left submandubular region.
the results of ultrasound examination are shown in Fig. 1. Surgical excision of the lesion was performed. However, 3 months later, another hard mass developed in the right upper neck and the sonographic feature of this lesion are shown in Fig. 2. What is your diagnosis? Are these two lesions related to each other?
Interpretation Conflicts of interest: All authors declare no conflicts of interest. * Correspondence to: Dr Chee-Wai Mak, Department of Medical Imaging, Chi-Mei Medical Center, Yong Kang District, Tainan City, Taiwan, ROC. E-mail address: [email protected] (C.-W. Mak).
Fig. 1 shows a well-defined 1.4 cm 1 cm oval heterogeneous mass with internal echogenic foci and a peripheral hypoechoic rim located in the subcutaneous layer of the left submandibular region. Surgical excision showed that
http://dx.doi.org/10.1016/j.jmu.2014.03.002 0929-6441
Please cite this article in press as: Mak C-W, et al., Hard, Tender Mass at the Submandibular Region and Trunk, Journal of Medical Ultrasound (2014), http://dx.doi.org/10.1016/j.jmu.2014.03.002
+
MODEL
2 this was a pilomatricoma. Fig. 2 shows a 1.1-cm calcified mass with an acoustic shadow in the subcutaneous layer of the right upper neck, which was also shown to be due to pilomatricoma, after surgical excision. Pilomatricoma also known as trichomatricoma, pilomatrixoma or calcifying epithelioma of Malherbe is an uncommon benign superficial tumor arising from the hair follicle. Pilomatricomas occur more often in children younger than 20 years old, with a slight female predominance. Frequently affected sites include the neck, head, and face, followed by the upper extremity. Patients affected usually present with an asymptomatic palpable mass with a rock-hard consistency and an irregular surface, which causes skin stretching over the mass. Most pilomatricomas have an excellent prognosis after complete surgical excision. Pilomatricomas are superficially located, small and movable masses, therefore, patients are usually treated without imaging studies. The sonographic features of pilomatricoma include: (1) a subcutaneous mass containing internal calcifications, internal echogenic foci, and a hypoechoic rim [1,2]; (2) an irregular, homogeneously hyperechoic mass with strong posterior acoustic shadowing [2]; and (3) a complex, pseudocystic lesion [3]. Furthermore, this tumor has been reported to be hypervascular [1,2,4], with 70% having peripheral color Doppler flow and 10% presenting with both central and peripheral color Doppler flow patterns [2]. The differential diagnosis includes epidermoid or dermoid cyst, salivary gland tumors, calcified lymph nodes, and hemangioma. Pilomatricoma can be distinguished from epidermoid and dermoid cysts by the presence of
C.-W. Mak et al. calcification and peripheral vascular flow. Epidermoid cysts appear as hypovascular masses with inner anechoic foci rather than echogenic foci and do not show vascular flow. Salivary gland tumors are deeply seated beneath the superficial fascia, whereas pilomatricomas are located within the subcutaneous layer. Hemangiomas are usually soft, their associated calcifications are round, and low frequency Doppler glows are evident within anechoic vascular channels. Most lymph nodes have central Doppler flow at their fatty hilum, whereas pilomatricomas tend to have peripheral Doppler flow. In conclusion, diagnosis of pilomatricoma should be considered when a well-defined mass with inner echogenic foci and a peripheral hypoechoic rim, or a completely echogenic mass with strong posterior acoustic shadowing in the subcutaneous layer of the head, neck, and extremity is found on ultrasonography.
References [1] Jin W, Kim GY, Park SY, et al. The spectrum of vascularized superficial soft-tissue tumors on sonography with a histopathologic correlation: part 1, benign tumors. AJR 2010;195: 439e45. [2] Hwang JY, Lee SW, Lee SM. The common ultrasonographic features of pilomatricoma. J Ultrasound Med 2005;24: 1397e402. [3] Solivetti FM, Elia F, Drusco A, et al. Epithelioma of Malherbe: new ultrasound patterns. J Exp Clin Cancer Res 2010;29:42. [4] Ichikawa T, Nakajima Y, Fujimoto H, et al. Giant calcifying epithelioma of Malherbe (pilomatricoma): imaging features. Skeletal Radiol 1997;26:602e5.
Please cite this article in press as: Mak C-W, et al., Hard, Tender Mass at the Submandibular Region and Trunk, Journal of Medical Ultrasound (2014), http://dx.doi.org/10.1016/j.jmu.2014.03.002